Home > Health Insurance Makes Me Crazy, The Best Health Insurance In the WORLD!!!! > “Covered Benefit” Does Not Mean It’s A Benefit That Will Be Covered

“Covered Benefit” Does Not Mean It’s A Benefit That Will Be Covered

Perhaps you might have wondered why I don’t blog so much lately. That would be because my full-time job these days is navigating the The Best Health Insurance System In The World!TM on behalf of my elderly mother.
You may recall that a few weeks back, her wallet was stolen, necessitating cancellation of her existing Blue Cross insurance number and issue of a new number and card. If you will recall, I explained that it appeared to providers in the interim as if my mother had no coverage.
Well, I finally received the new card with the new number. I spent a good deal of time this morning calling health care providers who had provided services to my mother during the interim period, to let them know what the new card number was so they could proceed with billing. We got the new card just in time, I thought – for as bad luck would have it, mom had another health care emergency today, and is in the ER as I type. My brother and sister-in-law are with her, and I gave them the new health care number to use at the hospital. I’m waiting for reports from them on how mom is doing.
And then I went out for a quick lunch, to get out of the house and decompress for a bit.
Upon returning home, I found a phone message from one of the providers I’d called in the morning. You guessed it: problems in dealing with the health insurance company.

The provider, a pharmacy that had dispensed a medication my mother needed for short term treatment, had spent one hour on the phone arguing with the health insurance company that the new number was valid and that my mother did, indeed, exist in the health care system. The insurance company was sure that she did not. I called the insurance company; they claimed there was no record of the provider calling to inquire about coverage for my mother.
At this point it was near 5 pm and the pharmacy and I agreed to give up for today and start again tomorrow. Part of what we think is going on is that coverage for medications is handled by a separate wing of the health insurance company, and they apparently have not yet gotten the information that my mother still has coverage. This, of course, begs the question as to why she ever had to be labeled as not having coverage in the first place. I mean, presumably you could invalidate an insurance number without invalidating a person covered on a policy, no? It seems to me that should be technically possible.
The very nice person at the pharmacy trying to help me navigate this maze and get my mother’s prescription paid for was very sympathetic to me when I said, “this is basically my full time job. This is what I do all day – deal with the health insurance issues of my mother. What do people do when they don’t have someone to help them out with this? Or how do they do it when they have to work all day and can’t spend all day on the phone chasing down this stuff?” She said, “This is why people go broke. They don’t have someone to help them sort through the problems and roadblocks, and they end up paying for bills they shouldn’t have to pay for. And there are so many roadblocks – and they are put there for a reason.” By now, she and I have collectively spent in time dealing with the health insurance company way more than the $140 worth of medication that was dispensed to my mother.
I have a friend who pays cash for Singulair allergy medicine ($5 per tablet) instead of the co-pay price ($0.50 per tablet) because after three hours on the phone trying to obtain authorization, he just gave up. He doesn’t use the medication on a daily basis, so he can afford to absorb the price.
But see, that’s exactly what they count on. They count on most people giving up in frustration, out of lack of time to deal with the inanities and roadblocks and frustrations and “we lost your claim, you’ll have to refile it” or maybe they just die while they are waiting for their case to wend its way through the system. People give up because they don’t know how to deal with the roadblocks, they don’t have time, they get beaten down by the sheer frustration of it, the impersonality of it. You can never talk to the same person twice, every time you call you have to repeat all the facts of your case from square one all over again. You think, how can it be worth it for them to spend three hours keeping me from getting my Singulair? But it isn’t just you, it’s everyone, and if 95% of the people give up, they just don’t have to pay for that “covered benefit”. That’s how they can afford these buildings to intimidate you with when you come downtown to argue your appeal case for your coverage. That’s how the fantastic salaries for their CEOs are made – every goddamned dollar of them earned through your frustration, your conclusion that it is easier to pay the $5 a tablet for Singulair than to spend who knows how many hours it will take on the phone to get your coverage – an argument you may have to go through not just once, but repeatedly.
I appealed for coverage for my botox treatments for my migraines, because absolutely nothing else works to prevent them, and because having had a stroke, most common prescription meds for treating migraines are contraindicated for me. And I had data showing that botox treatments actually worked. I went through three levels of appeal. I went to that fancy building downtown for a hearing. I prepared what amounted to a mini-clinical study report on myself, in a three-ring binder, complete with literature references, and handed it out to the appeals panel members. I convinced them to approve my treatment. I have a letter from them stating that I have approval to receive this treatment for my migraines. Yet, nearly every time I receive a treatment, I also get an “explanation of benefits” form (there’s an oxymoron if I’ve ever heard one) saying that coverage is rejected because the treatment is not a covered benefit. At which point I have to get on the phone, explain that I do have permission for coverage, and ask them to refile. At which point, inevitably, the person I am talking with says, “oh yes, I can see your letter of permission right here in your file.” So, you know, it’s not like it was hard to find. It’s not like they’ve never been through this before. It’s not like the person who first processed this instance didn’t know it was there or couldn’t find it. They just reject the damn thing hoping that this time, I’ll give up, and they won’t have to pay this one, and maybe never have to pay again.
Don’t talk to me about government-instituted “death panels”. The real death panels are the ones in that building in downtown Philadelphia, and similar ones belonging to other health insurance companies around the nation. The ones who attempt to stymie you at every turn in your efforts to access your “covered benefits”. The ones who hope you will give up, go away, or die before they ever have to get around to paying anything on any of your claims.

  1. August 25, 2009 at 7:19 pm

    Ugh, yes. Having family members who serve as providers you definitely speak truth. So much of having coverage means having the cultural capital and privilege of knowing how to navigate the system. I cannot help but remember the scene in The Incredibles where Bob gets in trouble for helping his clients know who to contact and what to say.

  2. dzdt
    August 25, 2009 at 7:20 pm

    The Pixar movie “The Incredibles” hit this point exactly right. Every time I hear this kind of story I flash back to the insurance executive there lamenting “They’re penetrating the bureaucracy!” when Mr. Incredible actually helps customers obtain coverage.

  3. August 25, 2009 at 7:30 pm

    amen, sistah. and worse, while you argue, not only are you getting frustrated, but you also have to budget time in to talk to the collection agencies that call you day and night, and then, when you don’t pay these medical bills because you only had enough money to pay rent last month and the month before that and the month before that .. etc., they file lawsuits against you which then involves lawyers and credit bureaus .. and the credit bureaus are only too happy to trash your credit rating over two unpaid medical bills (nevermind that you’ve paid every bill you’ve ever gotten previously, in full and on time!). after this, your credit rating is so trashed that you cannot pass a credit check to get a job — not even a measly crappy below-poverty wages job — nor find affordable housing if you dare move or get evicted for falling behind on your rent. and then you get to fight with all of these credit bureaus (all for-profit companies) for literally the rest of your natural life to restore your credit to a passable level. it’s a wonder to me that america doesn’t have 40 million suicides.

  4. anna
    August 25, 2009 at 7:41 pm

    As an American now working & residing in Canada, all I can say is, America- wise the hell up. Supporting the insurance industry, fighting reform- this will dig your own grave, almost literally. Yes Canada’s system may have some problems, but then again, what in life is actually perfect and running as planned? So what? People here do not need to mortgage their house or hold bake sales to pay for cancer treatment. They do not need to spend 17 hours a week on the phone with insurance folk. You will not be discharged from the hospital, even as a homeless person, without some offer of support in place- not that you are even obligated to accept this FREE help, which you have actually already paid for in lifetime taxes. You will not be denied care because of preexisting conditions- there is no insurer to deny the claim! Of course there are supplemental insurance policies to cover additional services, maybe upgrade some services or a room, but the Province still pays for the majority of care. Private insurance doesn’t cover primary care or hospital care. You do- through your taxes. You may have an MI, a stroke, paralysis, you name it, you will get care. And No Bill.

  5. D. C. Sessions
    August 25, 2009 at 7:44 pm

    it’s a wonder to me that america doesn’t have 40 million suicides.

    I know it’s annoying to have people tell you to be patient, but we’ll get there. Maybe only ten million to begin with, but we’ll get there.

  6. August 25, 2009 at 8:08 pm

    well, that’s one way to reduce the growing population, by specifically targeting the least desirable portion of the population, i suppose.

  7. Dr. Shrinker
    August 25, 2009 at 8:16 pm

    As a “healthcare provider” (we used to be called doctors before the insurance companies relabeled us) I can certainly empathize. I’m a sole practitioner psychologist and I try to do most of the navigation of the insurance labyrinth myself…it seems grossly unfair to just hand a bill to a patient going through emotional distress and say, “I couldn’t get your insurance to pay the right amount. Pay up.” Sometimes I do have to…other times I just get to eat it. (Not to mention that, even if they DO pay, most insurers haven’t raised reimbursement rates in 20 years for psychotherapy.)
    Everything you described in your post is 100% consistent with my experience. Complicating it for me is that so many of those “customer service” jobs are outsourced, meaning that I’m talking to someone with a thick, at times indecipherable, accent who has been given a manual of rote responses, none of which address the reason for my call.
    It truly boggles the mind how sleazy and dishonest these companies are. And I can NOT believe that the issues I call about are legitimate errors, when 98% of the time or more they favor the insurance company. It’s been a long time since I’ve done statistics, but I’m fairly certain that the null hypothesis has been disproved…

  8. August 25, 2009 at 8:45 pm

    You’ll like this one too.
    My five year old just had his second set of tubes put in his ears. It was an outpatient procedure that lasted less than an hour.
    The physician who performed the procedure was reimbursed less than $300 for skillfully wielding sharp instruments not too fair from my son’s brain.
    Meanwhile, the anesthesiologist was reimbursed $600 for passing gas. In addition, a CRNA was reimbursed $600 for who knows. We actually met the anesthesiologist whho said he’d be on the case. We never met the mystery CRNA.
    When we called Cigna to complain about the double billing, we were told that having two highly trained gas passers on outpatient procedures is standard procedure.
    It still makes me crazy when I think about.

  9. August 25, 2009 at 8:58 pm

    I could probably write a whole separate blog, one post a day, each day a new anecdote, of my frustrating encounters with the health insurance industry on behalf of my mother or myself.

  10. August 25, 2009 at 9:23 pm

    Damn fucking straight, Z! These sick-fuck right-wing deranged assholes can take their depraved immoral hateful motherfucking lies and shove them up their motherfucking asses. Preach on sister!

  11. Teddydeedodu
    August 25, 2009 at 9:40 pm

    Thanks for sharing your story. Sorry to hear about your predicament there, Zuska. I hope everything works out for you.
    Yes, that is why health care reform needs to happen! Im sure that your story is just one of so many out there that doesnt get reported because the people who are involved just simply gives up fighting the system. I really hate the selfish pieces of shits that populate the right-wing organizations in your country who are trying to sabotage this reform.

  12. jc
    August 25, 2009 at 9:43 pm

    (((Z and mom))), bucket o’ puke for the assholes, and big YAY! for having a really nice Pharm person’s help.

  13. August 25, 2009 at 10:25 pm

    Zuska, Amen! The insurance company did the exact same thing to us when my husband was disabled.
    The only clinic that had the right specialists who accepted his insurance fired them all. There were plenty of other doctors in town that he could have seen, but none of them accepted his insurance. The insurance company refused to authorize him seeing someone in town because there were people 50 miles away that he could see in-network — never mind that he’s disabled and can’t go there. They were counting on him not having a support system (me) who appealed to the state, which immediately put them back in line. But every time he went to the out-of-network doctor he was authorized to see at in-network prices, they “forgot” that it was authorized and I had to call them and get it corrected. In fact, I had to appeal to the state another time, and they once again complied right away.
    But I seriously find it hard to believe that these were all accidents — like you said, they’re counting on people to just eat it instead of fight. In our case, I was a grad student and he had been our primary breadwinner, so we were broke, and fighting with them was the only thing I could afford to do. But I shudder when I think about other people who have no advocate like you or me to handle their medical bills.

  14. August 25, 2009 at 10:54 pm

    I once got a remarkable change in service level and the hoops I had to jump through in depositing a cheque at another branch of the same bank, by presenting them with a bill for the 45 minutes it took to get my cheque deposited and the hold released and some money out every single time. They put an annotation on my bank card. Maybe if enough people set out to recover the cost of lost time and put the cost back on the insurance company, they wouldn’t be so eager to do it. $60 an hour is a nice average rate that you could be earning for knowledge-worker tasks if they weren’t wasting your time.

  15. August 25, 2009 at 11:03 pm

    And don’t forget interest on the unpaid bill–say, 1.2% a month after 15 days! I told them that I did not expect them to pay it, I just wanted them to know what it was costing me in lost income. So while they’re building their temples to mammon, think of the productivity loss. Do you know what that could do to your economy? Oh. I guess it already is.
    Metarules — are they allowed to fire doctors who are needed to serve the town they’re in? Or are there no standards?
    I read an article by a U.S. insurance co. employee who found a person the coverage they needed for an unusual procedure, which the company proceeded to trumpet as an example of their wonderful care, meanwhile firing the person who arranged it so she wouldn’t do it again.

  16. August 25, 2009 at 11:28 pm

    This makes me feel a bit better about not having health insurance.

  17. oh, I guess I"d rather not say this time
    August 26, 2009 at 12:42 am

    A few years back, Homeland Security decided all my records (including income tax and health insurance through work) had to use the birth certificate name, in all its ponderous multisyllabic Southern verbose goodness, instead of the name I’ve been called by ever since I was born.
    The health insurance company cheerfully discarded 25 years of health records and opened a new file — same SSI, new name. Then — as they had no record of any past history on my account — they cancelled and denied everything and insisted my health record start over from scratch.
    It certainly removed any risk I’d be treated as anything other than the statistical average patient.

  18. Luna_the_cat
    August 26, 2009 at 5:21 am

    If you don’t mind, I’m going to start sending a few people to read this post….

  19. Kea
    August 26, 2009 at 5:41 am

    Well, I am not so unfortunate as to be American, but this is more or less why I have no car, no house, no large assets, no insurance (except occasionally, travel insurance). No doubt I will die young … but no f$£&%*” Orwellian idiot is going to boss me around.

  20. Rose Colored Glasses
    August 26, 2009 at 6:18 am

    Adding fuel to the fire, remember when hospitals began going to for-profit because competition would drive down costs?
    Then the insurance companies began buying up hospitals and jacking up the prices. If you have lots of money, the hospital will be happy to pocket it. If you don’t have much money, the insurance racket will take what you have, and then cheat you out of what you’ve been paying for, simply because they know if you need them then you’re too poor to have a judge friend hit them with a court order.

  21. Carlie
    August 26, 2009 at 8:10 am

    I just last week finished up a two-year battle with my insurance company over a $400 leftover emergency room charge. Two years, during which the hospital twice tried to send it to collections before I managed to stop it and remind them to look at the file that showed a few dozen calls back and forth trying to resolve it. And this wasn’t even a disputed charge, really, the hospital was just out of network and didn’t know how to file it properly, so the paperwork had to be refiled several times before everyone was satisfied. And I have what one could easily describe as premium gold-plated insurance. The kicker? The original visit was for an anaphylactic reaction to nuts, and although we ran in screaming “allergic to nuts and had some and we don’t have the epi-pen with us”, we didn’t get anything but Benadryl, and that came almost 3 hours after we had walked in. Yeah, that was really worth it.

  22. August 26, 2009 at 8:52 am

    This is a horrible combination of FUD, and driving cost to their feet.
    However as sad as it may sound that is their business you ensure 1000 and 900 never do a claim bigger than their payment.

  23. Betty Primus
    August 26, 2009 at 11:20 am

    As I keep saying: as long as the best way for an insurance company to make a buck is to pay someone $9/hour to refuse a $10 claim, the U.S. will drown in administrative costs.
    You need single-payer to avoid this ridiculous game of hot potato.

  24. a little night musing
    August 26, 2009 at 1:21 pm

    A terrible story, and all too common. I’ve gone through a lesser version myself.
    And there is nothing in the bills making their way through congress right now that would prevent this sort of thing in the future. So I don’t know why we should be happy if more people are required to buy this sort of “insurance”.

  25. August 26, 2009 at 2:56 pm

    One of the insidious things about this debate is that not everyone experiences such obstacles. It’s easy to say “Well, my insurance paid $100,000 for my cancer treatment without batting an eye, therefore it’s not the system that’s broken, you just have bad insurance.” Of course, the system is broken: they provide good service to just enough people to create the impression that the anecdotes of horrid experiences are anomalies.
    musing: I believe the theory is that if individual insurance policies are made available (no denial for pre-existing conditions) and affordable (no charging higher premiums to sick people; government aid for low-income families), market forces will favor insurance companies that develop good reputations. Right now, most people have no choice: their only option for insurance is the single plan their employer offers. That’s hardly a “free market”.

  26. jc
    August 26, 2009 at 6:23 pm

    As a healthcare provider I can say that while collecting from the government is much easier than collecting from the health insurance companies, government bureaucracy does impose arbitrary caps and limits on various services. And such caps and limits are probably inevitable because uncapped government systems tend to go broke (as it has been said Medicare is on track to do).
    The elimination of pre-existing condition exclusions might be another important element in any future health insurance regulation. The social purpose of insurance is to “spread risk”. It appears that current insurers do not currently view their role as “assuming risk”. It appears that they may collectively think that their primary responsibility is not to the patients they insure, but rather to themselves and their shareholders. The insurance companies may need to be reminded of their role; perhaps through legislation/regulation and legal action.
    In my humble opinion, it would be better to have a highly regulated private insurance system that would not be allowed to wage war against, and rob, patients and providers by passive-aggressively obstructing both payments to providers and written guarantees of payments to both patients and providers.
    Additionally, if patients could get “de-coupled” from the employer-based system of health insurance and buy their own health insurance (by receiving a voucher from their employer and a tax-credit for the balance), then at the first sign of dishonesty on the part of an insurance company the purchaser/patient could “vote with their feet” (i.e., walk away from/fire that insurance company and get a new one). There should be mandates for people to have health insurance. We are required to have auto insurance in California. One might say, “Well, it only hurts me if I don’t have health insurance, so I shouldn’t be required to have it”. That’s not true. Emergency rooms are required to take all patients who present for service. We all pay for that in variety of ways (taxes, cost-shifting, etc.) Hence, one should not be allowed use an employer funded voucher or receive a tax credit if they don’t use it to buy health insurance.
    Finally, the idea of health savings accounts is probably a good one. One can err to far on the side of believing that others are totally responsible for their well-being. Insurance has traditionally existed for the purpose of indemnifying entities against catastrophe. It’s not to pay for routine things. When one need’s a new battery or tires for their car they don’t get their insurance company to pay for those things. Further, the only “grown ups” who get other’s to pay for their food at the supermarket are people who use food stamps. People of average means or better should pay for their own “basic” health care out of their pocket, up to a limit ($5000/annually?). Beyond that limit their situation would be defined as “catastrophic” and insurance should be forced to “kick in”. It has been said that an inordinately large amount of money currently paid by insurers currently is for routine (i.e., office visits for the flu, etc.) medical services. These kinds of things should be “out of pocket”
    OK. That’s my rant. Thanks

  27. katydid13
    August 26, 2009 at 11:24 pm

    I have excellent health insurance because I work for the federal government. (Although, I would like to point out that is not free, I pay a good bit for it. I’m a little tired of hearing about my free health care).
    I hurt my knee needed an MRI a little over a year ago(well, I would say the need was questionable, but that is a whole different story). I went online and looked up providers on my insurer’s website. They showed no radiologists or MRI centers as being in their network in the great DC Metro area. I assumed that there was a flaw in the database.
    So I call the 800 number to find a provider and I’m told that the computer says there are not providers in the Washington, DC area, but I can go to Richmond, VA (several hours away). I explain that I’m pretty sure this is mistake. They insist there is no mistake. I decide to hang up and call back later assuming I’ll get someone less stupid.
    I call back later and I do get a different person, who does sort of try. She tries to tell me that maybe the reason that I can’t get and MRI in DC is that we don’t have any MRI machines. I explain that there are 3 medical schools and teaching hospitals in DC so I’m fairly certain that we have the equipment. I also explain that I’m pretty sure you aren’t allowed to be part of the federal employees health benefit plan in DC and not allow access to something like an MRI. I also ask to talk to a supervisor, but apparently I’m not allowed to because the computer is never wrong.
    Then I decide to take advantage of the fact that I work in a huge federal agency and start asking around to see if anyone who uses the same plan I do ever got an MRI and get some leads that way and find out that I can indeed get an MRI at little place called the George Washington University Hospital.
    I’m cranky and in pain so while I’m waiting to my networks to work and come up with a place to get an MRI, I call HR and ask them if there is any kind of ombudsperson or anything at the Office of Personnel Management, which manages stuff like health insurance for federal employees. This request totally confuses them, which shouldn’t shock me because these are the same people who when I was trying to get my prior federal service in the office of Senator counted, told me that “the Senate isn’t part of the federal government.” I did finally win that one, but it was struggle.
    That made me even more cranky so I poked around on the OPM website and found an email address for problems or concerns. I didn’t really think anything would happen, but I wanted to vent. So I sent an email explaining the kind of stupid I was dealing with. I got an immediate phone call back saying that of course I was apparently dealing with morons and the would have someone from the company who knew something call me back. They did and of course apologized for the stupid and said that their employees were supposed to check the paper handbook when they got an old result like that.
    I am fairly certain that one reason that I got a reply so fast is that I work for an oversight agency that does things like report to Congress about how OPM does their job. That’s obvious from my email address. I didn’t mention that or try to pull rank and I’m not even that important, but my guess is someone decided not to risk messing with my agency. Plus, the company was clearly giving me the wrong info.
    This worked out fine for me, but it was a pain. It was a pain and I was operating from a pretty strong position of privilege. I have a desk job where I can do paperwork and argue with insurance company staff at the same time and no one cares. I work for a government agency that scares other government agencies. I also have a better than average understanding of how the federal system works and a strong ability to navigate bureaucracy. And I have good insurance. It wasn’t even a question of payment, it was just cutting through the stupid to get someone to recognize a fairly obvious mistake. If this is what having good insurance is like, I’m a little scared about what someone who has bad insurance and fewer resources than I do has to put up with.
    You can bet I use a different insurance company this year.

  28. Jonesy
    August 27, 2009 at 8:08 am

    Isn’t this akin to mail fraud?

  29. Left_Wing_Fox
    August 27, 2009 at 6:07 pm

    I think you’re assuming that people who cannot afford healthcare _now_ will _never_ be able to pitch in for healthcare.
    This is simply not true, in many ways.
    First, the costs of your medical procedures inclused the cost to the hospital of the procedures unpaid for due to bankruptcy or delinquency. You a;lready ARE subsidizing the healthcare of others, just in the least efficient way possible.
    By allowing those who couldn’t afford insurance a method of paying into the general pot, those who would otherwise not be contributing ANYTHING would then at least be contributing SOMETHING.
    Same with those who lose coverage through job loss, pre-existing conditions, or unaffordable rates.: they would still continue paying into the system in a universal plan.
    If you’re really worried about illegal aliens, they aren’t necessarily going to be covered any more in a socialist system than they are now: folks without a provincial health care card get billed for services.
    In the end, this is enlightened self-interest. I pay for others, because others will pay for me. I pay less for more choice. I have more real freedom than in the US healthcare market. If you’re rejecting that on principal, your principals are out of whack.

  30. Left_Wing_Fox
    August 27, 2009 at 6:09 pm

    Damn, wrong thread. 😛 Where’s my coffee…

  31. Peggy
    August 27, 2009 at 6:27 pm

    JC: Your comparison of mandatory health insurance to mandatory car insurance isn’t really a very good one. Cars aren’t necessities, and people who can’t afford a car and the insurance that goes with it take public transit, or walk, or catch rides from other people, even here in Southern California which was largely developed for the convenience of people with their own wheels.
    Also, car insurance is much less expensive than health insurance. Offering a tax credit doesn’t help people who are struggling to pay rent and buy food every month. And the self-employed and minimum wage workers (not to mention unemployed) who have no employer-provided health insurance now aren’t going to have the benefit of employer-provided vouchers.
    And finally, car insurance usually only covers catastrophes – serious damage or theft. It doesn’t cover maintenance or basic repairs. Equivalent health care insurance wouldn’t cover routine check ups or even basic medical care. Those people who end up in the ER because they have no other regular access to a doctor would likely still end up in the ER.
    And one more comparison just to beat the analogy to death: my own car insurance gives a discount if you’ve been accident-free for five years. For health insurance purposes, pre-existing conditions are forever (sobering when you read horror stories like these). If an insurer provides poor service to you, simply the fact that you submitted a claim can work against you finding affordable coverage with another provider.
    I think there will need to be major changes to the private health insurance business model, which currently encourages them to deny every claim if at all possible and makes it difficult for the insured to understand and navigate the appeals process, before mandatory private health insurance is a good option.

  32. JC
    August 28, 2009 at 4:31 am

    I agree with you about automobile insurance being different than health insurance and I think I understand your points.
    My only reason for bringing up the requirement for all to have auto insurance is to point out to those who seem to feel that the young and healthy should be exempt from being required to have health insurance is because if they don’t have health insurance then we have the problem of some of them showing up at the E.R. when they (unexpectedly)get sick or injured to receive services for which many of them will not pay, therefore resulting in the hospitals and doctors having to “eat” or shift the costs.
    We do not live in a society that is so uncaring that the medical establishment has a policy of denying essential (and sometimes very costly) care to those who need it. I realize that insurance companies do do that; however, I do not consider them to be part of the medical establishment.
    So we have to make some decisions: what is medically necessary and what is not, what are we willing to pay for and what are we not. And we have to have to have as many people paying into a health insurance system as possible in order to “spread risk”.
    And we have to decide what are the limits to which we will go in regulating the spreading of risk. If you allow the health insurance companies (the traditional social organ that manages medical risk) to write their own rules and to be primarily beholden to themselves and their shareholders, with only secondary consideration for the patients that they have agreed to “insure” (at least we think they have), then what do we need health insurance companies for? They are parasites. We should withdraw all funds from them, allow the health insurance companies to die a natural death, and find a better way to spread medical risk.
    I know I get referrals all the time in the hospitals I go to to see patients who are coded as “self pay” (translation: they don’t have health insurance). I’m sorry if this offends anybody, but it really annoys me when that happens. I don’t know any other group of workers who are expected to work for free. I don’t mind doing some “pro bono” work but I want to have the choice when I do so.
    As previously said, some ways to deal with this include the “government option” and “single payor”. However, as also previously said, study of the systems of other countries (and our own Medicare and Medicade systems) shows that ultimately rationing care and eliminating many service that are not absolutely required in order to “keep people alive right now”, is necessary in those systems in order to keep them solvent. So under such systems we can provide emergency care to a stoke victim, but then what’s the point if they can’t get rehab to help them recover their functional abilities. We can provide acute psychiatric hospitalization to a person following an episode of suicidal behavior but then what’s the point if they can’t get psychotherapy (or enough psychotherapy) to help them change the behavior patterns and strengthen their abilities to cope with the stressor(s) that led them to choose suicide in the first place.
    In my first post, I meant that all working people (regardless of their age and health) should be required to be in the insurance purchasing pool. This idea that “I’m young and healthy, so I’m not going to have health insurance” appears at first blush to be consistent with our nation’s value that people should be “free to choose” how they live their lives as long as their choices don’t affect others. But that also assumes that they have to live with the consequences of their choices. So if they don’t get health insurance and then they get treated for free, then they are “having their cake and eating it too” and we shouldn’t allow that. Ultimately, not having health insurance does negatively affect others when that person gets sick.
    Also, not taking care of one’s health, smoking, neglecting one’s diabetes, being obese, not controlling one’s cholesterol, not exercising, etc. ultimately does affect others. If one is are overweight, smokes, drinks excessively, etc. they will be more prone to have diseases that are costly to treat. That will drive premiums (or taxes)of others up. Worse, if the obese alcoholic who smokes and/or who neglects his diabetes and cholesterol has no health insurance, guess what?
    So the idea of personal freedom is a relative one.
    I only brought up the auto insurance analogy to build the case that there is a precedent for requiring others to have insurance.
    That said, your other points are quite correct I think.

  33. mj
    August 28, 2009 at 1:57 pm

    I have another jumping through hoops insurance story (they seem to be a dime a dozen). I had to take my son to the ER a few months back for a broken leg. My insurance carries a $30 copay for ER visits. No problem, I will happily pay my $30. They didn’t collect it in the ER but sent a bill after the fact and I paid it immediately.
    A month later I received a bill for the same $30 copay. I called the insurance, explained that I had already paid and I had looked online and they indeed had cashed the check. I was told to fax a copy of the canceled check, which I did immediately.
    One month later I got another bill. I called the insurance company yet again. I was told that oh yes, we did receive that payment long ago, but it was posted to the wrong claim. Please disregard the latest bill and I will have your $30 moved to the correct claim.
    Two weeks later there was a message on my answering machine from a BILL COLLECTOR. Now, I happen to have excellent credit, pay my bills on time, and have never had money troubles in the past. This scared the crap out of me. The bill collector informed me that they needed to collect my $30 immediately. Ok, it’s only $30, but I was not going to pay out of principle. I had already paid and I was not going to let the insurance company get away with their mistake.
    I wrote a long letter documenting all of my calls with insurance (including names and times that I spoke with people) and sent a copy of the canceled check to the bill collector. I also called insurance again. How many times is this now? I’ve lost count. I am told yet again that the money will be moved to the correct claim. I call back later in the day to make sure it has been moved. It has not and I require them to transfer me to a supervisor. Apologies all around, we will get this fixed. Three days later I finally get a call from the insurance company that my account reads that I have a zero balance and a month later receive a paid in full letter from the bill collector.
    How much money was wasted on this mistake (that I informed them of twice)? A lot more than the $30 in question. This is how people’s lives and credit get ruined. Stupidity at the hands of insurance companies.

  34. D. C. Sessions
    August 28, 2009 at 4:29 pm

    MJ, I went through the same thing — and this was back when copies of cancelled checks from the bank (the only acceptable proof, it seems) were costing $30 each. I did it once, and the second time around told them that they could pay me for my expenses and time off work at my usual hourly rate. If, as threatened, they sent it to collections I’d file in small claims court for statutory damages for frivolous injury to my credit rating — and they could either send someone authorized to represent the company or lose by default.
    Ball in their court.
    I never heard back. My credit remains unblemished.

  35. Peggy
    September 1, 2009 at 3:20 am

    JC: I agree that it would be optimal if everyone, regardless of age and health status, was part of the insured pool. That not only spreads the risk, but provides a safety net for the formerly healthy if they are met with unexpected medical care needs. However, I don’t think that the assumption that many young people reject buying insurance solely because they don’t believe they need it is the complete story. I know several people in their 20s who don’t have insurance and talk about it in that way – but the reality is that they don’t have insurance benefits through their jobs (and one is unemployed) and they are struggling to make ends meet. “I don’t need insurance because I’m young and healthy” can be a way of rationalizing when one is barely able to scrape together rent every month. Add to that the common stories about insurance companies denying claims and canceling policies and I understand their reluctance to buy into the system.

  36. hoolia
    September 3, 2009 at 9:01 am

    Thanks, Dr. Shrinker. I had a fun experience of crying to my therapist for half an hour because I was a broke grad student having stressful financial troubles while also working on my dissertation … and having her then have to break the news that my insurance company had stopped covering our sessions and refused to pay her, to the tune of seven hundred dollars.
    Kafka-eqsue black comedy, anyone? Seriously, it was so awful all we could do was start giggling – me and my shrink.

  37. pregunta
    September 4, 2009 at 5:06 pm

    I am one of the oh-so-fortunate people who can only buy health insurance from the state high risk pool (SHRP), if I want any coverage at all.
    I was really lucky that the underwriters accepted my application after having paid a former employer a couple thousand dollars of COBRA premiums which were pocketed instead of being paid to the health insurance carrier, which necessitated my application to the SHRP.
    And I’m even more fortunate to have gone through a medical coding and billing course, so when it comes time to do battle with the third party administrator for SHRP, I can see the “customer service representative’s” CPT code, raise her one and ante up a couple ICD codes as well. They hate when that happens.
    There is nothing wonderful about the US health care system, except when you look at your EOBs (should you be so lucky as to have health insurance) and think, “I wonder how the heck they mucked *this* up!”
    There is nothing advanced about the US health care system, except the new and ever-increasing ways health insurance companies and others come up with to delay and deny. Delay and deny treatment, delay and deny payment, delay and deny answers for legitimate questions and concerns…
    There is nothing beneficial about the American health care system that: forces ER physicians to work for free much of the time; discourages medical students from becoming primary care/IM physicians because they won’t be able to feed their families and pay off their student loans; has the highest costs and the lowest outcomes in the OECD; compensates executives outrageously, and fails to cover all American citizens at affordable rates without discrimination and prejudice.
    Most of the OECD countries’ health care systems use health insurance companies that are non-profit, well-regulated, and obliged to cover all.
    There will never be a free market in US health care – it’s past time for America, as a nation, to face up to its collective illness and take its medicine – health care reform.

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